56 y/o, f

[Christopher]

HR: 150-170, 4Lead ECG shows PSVT, 12 lead: PSVT

Booo! Booooo! It is only "PSVT" if you watched it start and stop. That term is a bad term anyways. "Narrow complex tachycardia" and "wide complex tachycardia" are better. SVT isn't a rhythm and apparently only exists to confuse people.

If by "150-170" you meant a ranging heart rate? Only three narrow complex tachycardias meet that definition:

• Sinus tachycardia
• Atrial fibrillation
• Atrial tachycardia (but not a huge range)
• Atrial flutter with variable conduction and "150-170" is the rate displayed by the cardiac monitor's moving average (unlikely)

If by "150-170" you meant, "somewhere exactly between those two", I would add the following are differentials separated by rhythm interpretation and not by rate (ordered by likelihood given patient's age):

• Sinus tachycardia
• AVNRT
• AVRT
• Atrial flutter (2:1)
• Atrial tachycardia
• Junctional tachycardia

 

[mycrofft]

CVA with these s/s seems very unlikely. Why couldn't she get up ORIGINALLY, did she get dizzy? (later on,probably). Any ortho issue which kept her from getting to the toilet, getting water and food, etc., like broken hip or a blown knee?

Saw a similar situation in a man who fell (had Parkinson's) and wedged between tub and toilet for three days, his barking dog summoned help (neighbors called landlord). Similar findings.

 

[Rykielz]

a

May I ask why?

She needs an ALS workup and transport to definitive care but she doesn't need you running around like a chicken with your head cut off. Despite popular belief, there's very few things where seconds truly count.

The call you referenced is much more severe than the one originally described in this thread.

She's dehydrated. Severely. She doesn't need medications or electricity. She needs fluids and electrolytes. 150-170 isn't that fast for a 56 year old. It's fast and needs to be addressed but she's not going to crump on you. Take the numbers you're getting and combine them with your patient's presentation and decide on the best treatment path.

So you want to give a severely hypotensive patient versed to cardiovert her? Versed isn't as scary as medic school makes it out to be but if she's stable enough for you to mess around with getting a line and drawing narcs she's stable enough for you to start a fluid challenge and consider chemical cardioversion before lighting her up like the morning sky.

You said you'd be wary of adenosine because "she's unstable and hypovolemic, cardioversion is a better option". How is cardioversion even an option in this instance? What is cardioverting a hypovolemic patient going to do for them other than hurt? Replace the volume, see what that does then reconsider your plan of action...

Where the heck did a CVA assessment come into play? I'm all for being thorough but nothing here says stroke to me at all. Maybe I'm missing something but you can do a pretty solid neurological assessment by just interacting with a patient. She complained of generalized weakness, not unilateral weakness....

As I said cardioverting was unlikely to work. Adenosine even more so. But I work in California, which is a mother-may-I system and on that call they'd tell me to cardiovert if the fluid didn't work. Not my choice it's how my protocols are written. When I originally wrote that I did not know that the fluid had worked. Which is why the other treatments were listed. Assuming the fluid didn't work that would've been the only option left other than continuing to pump her full of fluid.

Are you telling me that generalized weakness can not be a stroke? Not every stroke presents the same. Is it an unlikely diagnosis? Yes. Does it mean you can rule it out? Absolutely not. You cannot get tunnel vision on any call because the one time you do that'll be your license.

 

[Rykielz]

It also says directly in our protocols Adenosine is for stable SVT. This patient is without a doubt unstable when you look at her BP.

 

[Christopher]

It also says directly in our protocols Adenosine is for stable SVT. This patient is without a doubt unstable when you look at her BP.

That's not exactly true.

Adenosine is for tachycardias likely to be due to reentry mechanisms, whether they are stable or unstable makes no matter for its efficacy. Adenosine will not "fix" a stable sinus tachycardia nor a stable atrial tachycardia nor a stable atrial flutter or atrial fibrillation.

I've had stable patients with blood pressures in the 60's. They were in septic shock, but answered all questions appropriately and without hesitation. They most assuredly did not need cardioversion or adenosine for their tachycardias.

You must understand that cardioversion is for patients unstable DUE to their tachycardia. If their tachycardia is a compensatory response then cardioversion (whether chemical or electrical) is CONTRAINDICATED.

Atrial fibrillation with RVR is not always the cause of a patient's hemodynamic instability. Hypovolemic patient with a GI bleed and AF w/ RVR @ 140-170 will not respond to cardioversion no matter how many times you do it. They also meet the definition of unstable...

Sinus tachycardia is never* the cause of a patient's hemodynamic instability. (* you may only replace 'never' with another word if you actually can name the forms of sinus tachycardia that may cause hemodynamic instability)

Treatment of tachycardias is not rate based nor blood pressure based nor stable versus unstable.

Treatment of tachycardias is based on the appropriate rhythm interpretation in light of the patient's clinical presentation. This is not contradictory with ACLS or Paramedic curriculum or any protocols.

I'll add that if you are electing to cardiovert a narrow complex tachycardia that is not atrial fibrillation with RVR or atrial flutter, you need to take a step back and seriously evaluate what you are doing. Narrow complex tachycardias other than those two are almost always well tolerated even for prolonged periods of time. You would be well served to have already gone down the list of fluids, valsalva, adenosine, and a really hard look at H's and T's...

 

[Hunter]

This is a very sick woman and I'd get her going asap. First thing i'd do before I left scene is grab her meds. You said she's been off the HTN RX because her BP was getting too low? That could be part of the problem today. Check her lung sounds (i=Is she SOB? Do I hear rales?). I'd look at the stool too. Is is bright red? Black? Foul or unusual odor? She could be bleeding out internally. If she hasn't eaten in 2-3 days and those are her vitals that is another red flag. I'd be cognizant of dehydration and malnutrition. Has she been vomiting as well? If so, what color is the emesis? Palpate the abd (make sure there's no pulsating masses or abnormal distention). Another great thing to grab would be her grips/pushes and have her smile for the differential diagnosis to r/o stroke. Then check her pedal and brachial (since radial probably won't be felt) to make sure they're present and equal. As far as treatment I'd do this:

1) Place her in shock position
2) Oxygen 15 LPM via NRB
3) Cardiac monitor (Have my partner perform a 12-lead)
4) Bilat. large bore IV (grab a bs as well)
5) NS fluid bolus (That could very well correct her HR and her BP)
6) I'd be careful with adenosine. She's unstable and this appears to be
a hypovolemia and not a conduction issue. Cardioversion (Versed
beforehand for pre-cardioversion)may be the better option although
that probably won't do much either.
7) Perform another 12-lead if I'm able to get the HR to slow down. This
could very well be an MI as well.
8) Get her to the hospital asap. She needs the higher level of care.

***I had a call very similar to this. 30-ish y/o female fell suddenly had been sob for several days. By the time we got there she was lethargic and unable to speak due to her breathing. VS: 230 HR SVT, BP 70/P, RR 60 rapid and shallow. LS were absent in the bases with rales heard in the upper lobes bilat. I ended up popping bilat. large bore IV's in her, bagging, and cardioverting her 3 times which didn't do anything. I wanted to put her on CPAP but she did not meet the criteria according to my protocols. Well when we get her to the hospital the doc put her on their CPAP and she was fixed within 10 minutes; full sentences and everything. Never had an SVT call like it since.***

She's awake, talking moving around and you want to jump to zapping her??

Fluids, watch her for fluid overload, consider adenosine maybe...

Using the 220-age rule she's barely into the SVT range...

^This was the point of the thread, figure out why the patient has the signs and symptoms that she does and treat the cause of them.

She was alert x3, responding appropriately I'm not sure why you call her unstable, yes the vital signs aren't the best but I would consider her borderline stable.

She wasn't in respiratory distress whatsoever, she was at 94%, and respirations where 14, the O2 at 15LPM seems like a bit much and I think this is one of those situations where it would've hurt her instead of helping.

Her BSG was normal, don't remember the exact number.

Second 12 lead was sinus-tach at about 130

May I ask why?

She needs an ALS workup and transport to definitive care but she doesn't need you running around like a chicken with your head cut off. Despite popular belief, there's very few things where seconds truly count.

The call you referenced is much more severe than the one originally described in this thread.

She's dehydrated. Severely. She doesn't need medications or electricity. She needs fluids and electrolytes. 150-170 isn't that fast for a 56 year old. It's fast and needs to be addressed but she's not going to crump on you. Take the numbers you're getting and combine them with your patient's presentation and decide on the best treatment path.

So you want to give a severely hypotensive patient versed to cardiovert her? Versed isn't as scary as medic school makes it out to be but if she's stable enough for you to mess around with getting a line and drawing narcs she's stable enough for you to start a fluid challenge and consider chemical cardioversion before lighting her up like the morning sky.

You said you'd be wary of adenosine because "she's unstable and hypovolemic, cardioversion is a better option". How is cardioversion even an option in this instance? What is cardioverting a hypovolemic patient going to do for them other than hurt? Replace the volume, see what that does then reconsider your plan of action...

Where the heck did a CVA assessment come into play? I'm all for being thorough but nothing here says stroke to me at all. Maybe I'm missing something but you can do a pretty solid neurological assessment by just interacting with a patient. She complained of generalized weakness, not unilateral weakness....

.
Agreed with most of this, however a medial CVA would cause general weakness, but it would've also caused other symptoms which is why we didn't suspect it, dysphagia, aphagia, ect.

Booo! Booooo! It is only "PSVT" if you watched it start and stop. That term is a bad term anyways. "Narrow complex tachycardia" and "wide complex tachycardia" are better. SVT isn't a rhythm and apparently only exists to confuse people.



If by "150-170" you meant a ranging heart rate? Only three narrow complex tachycardias meet that definition:

• Sinus tachycardia
• Atrial fibrillation
• Atrial tachycardia (but not a huge range)
• Atrial flutter with variable conduction and "150-170" is the rate displayed by the cardiac monitor's moving average (unlikely)

If by "150-170" you meant, "somewhere exactly between those two", I would add the following are differentials separated by rhythm interpretation and not by rate (ordered by likelihood given patient's age):

• Sinus tachycardia
• AVNRT
• AVRT
• Atrial flutter (2:1)
• Atrial tachycardia
• Junctional tachycardia

It would go up and down between 150-170, once we reassessed after the fluids her heart rate was at 125-135 (as in i'm not sure what it was, but it was somewhere around there).

CVA with these s/s seems very unlikely. Why couldn't she get up ORIGINALLY, did she get dizzy? (later on,probably). Any ortho issue which kept her from getting to the toilet, getting water and food, etc., like broken hip or a blown knee?

Saw a similar situation in a man who fell (had Parkinson's) and wedged between tub and toilet for three days, his barking dog summoned help (neighbors called landlord). Similar findings.

No ortho, only history was hypertension, she said she couldn't get up because she had been getting weaker over time.

It also says directly in our protocols Adenosine is for stable SVT. This patient is without a doubt unstable when you look at her BP.

A BP alone is not the only thing that would determine if a patient is stable or unstable, as many EMT/Medic instructors have said, treat the patient not the monitor(sorry I know some people don't like this saying.)

That's not exactly true.

Adenosine is for tachycardias likely to be due to reentry mechanisms, whether they are stable or unstable makes no matter for its efficacy. Adenosine will not "fix" a stable sinus tachycardia nor a stable atrial tachycardia nor a stable atrial flutter or atrial fibrillation.

I've had stable patients with blood pressures in the 60's. They were in septic shock, but answered all questions appropriately and without hesitation. They most assuredly did not need cardioversion or adenosine for their tachycardias.

You must understand that cardioversion is for patients unstable DUE to their tachycardia. If their tachycardia is a compensatory response then cardioversion (whether chemical or electrical) is CONTRAINDICATED.

Atrial fibrillation with RVR is not always the cause of a patient's hemodynamic instability. Hypovolemic patient with a GI bleed and AF w/ RVR @ 140-170 will not respond to cardioversion no matter how many times you do it. They also meet the definition of unstable...

Sinus tachycardia is never* the cause of a patient's hemodynamic instability. (* you may only replace 'never' with another word if you actually can name the forms of sinus tachycardia that may cause hemodynamic instability)

Treatment of tachycardias is not rate based nor blood pressure based nor stable versus unstable.

Treatment of tachycardias is based on the appropriate rhythm interpretation in light of the patient's clinical presentation. This is not contradictory with ACLS or Paramedic curriculum or any protocols.

I'll add that if you are electing to cardiovert a narrow complex tachycardia that is not atrial fibrillation with RVR or atrial flutter, you need to take a step back and seriously evaluate what you are doing. Narrow complex tachycardias other than those two are almost always well tolerated even for prolonged periods of time. You would be well served to have already gone down the list of fluids, valsalva, adenosine, and a really hard look at H's and T's...

I agree and fluids would be part of the H's & T's, and it's how we figured out what was wrong with her.

 

[Christopher]

It would go up and down between 150-170, once we reassessed after the fluids her heart rate was at 125-135 (as in i'm not sure what it was, but it was somewhere around there).

This right here was your answer! A ranging heart rate + tachycardia narrows it down greatly.

You know:
(1) it is automatic not reentry (excluding the very rare possibility of flutter w/ variable conduction, but that should be obvious)
(2) it is either sinus tach or atrial fibrillation

Best to avoid "PSVT" as people like to cardiovert that inappropriately apparently.

 

[Aidey]

How long before your arrival did the pt fall?

 

[Aidey]

This right here was your answer! A ranging heart rate + tachycardia narrows it down greatly.

You know:
(1) it is automatic not reentry (excluding the very rare possibility of flutter w/ variable conduction, but that should be obvious)
(2) it is either sinus tach or atrial fibrillation

Best to avoid "PSVT" as people like to cardiovert that inappropriately apparently.

Why do you say flutter with a variable conduction ratio is a rare possibility?

People like to cardiovert anything over 150 bpm.

 

[Christopher]

Why do you say flutter with a variable conduction ratio is a rare possibility?

People like to cardiovert anything over 150 bpm.

Rare that it would range with an effective rate between 150-170.

 

[Aidey]

Rare that it would range with an effective rate between 150-170.

Ahhh, right. Because it would require primarily a 2:1 conduction with occasional 1:1 beats to elevate it over 150. Even more 1:1 beats if there are any 3:1 beats in there.

 

[Hunter]

How long before your arrival did the pt fall?

about 2-3 hours before we got there.

 

[Aidey]

So the poor oral intake preceded the fall. She wasn't not eating or drinking because she was on the floor. Was she able to provide a reason she hadn't been consuming anything?

 

[Hunter]

So the poor oral intake preceded the fall. She wasn't not eating or drinking because she was on the floor. Was she able to provide a reason she hadn't been consuming anything?

too weak to go to the bathroom, so she didn't wanna eat anything so she wouldn't have to.

 

[mycrofft]

too weak to go to the bathroom, so she didn't wanna eat anything so she wouldn't have to.

Chronic and worsening cardiac trouble can do that towards the end. End of the slide.

 

[Uclabruin103]

Into just my third week of medic school, so be gentle. What were her skin signs? I'd go towards the lines of shock due to the dehydration. She's tachycardic with a low BP, I'd address that first with a fluid challenge and maybe a vasoconstrictor then see if that helped with the HR. If not.... We haven't gotten to that yet!

 

[Handsome Robb]

As I said cardioverting was unlikely to work. Adenosine even more so. But I work in California, which is a mother-may-I system and on that call they'd tell me to cardiovert if the fluid didn't work. Not my choice it's how my protocols are written. When I originally wrote that I did not know that the fluid had worked. Which is why the other treatments were listed. Assuming the fluid didn't work that would've been the only option left other than continuing to pump her full of fluid.

Are you telling me that generalized weakness can not be a stroke? Not every stroke presents the same. Is it an unlikely diagnosis? Yes. Does it mean you can rule it out? Absolutely not. You cannot get tunnel vision on any call because the one time you do that'll be your license.

The way you worded it indicated you were jumping straight to it. "Cardioversion with versed for sedation is a better option"

No it's not. Correct the underlying problem and you fix the numbers that you're so focused on.

Generalized weakness can be a stroke but there's nothing about the presentation of this patient that indicates a CVA to me. Generalized weakness with a fall is her only complaint. Could it be. CVA? Sure! Does her weakness have something to do with her hypovolemia? That'd be my first guess. Not a CVA.

No one is taking your license for tunnel visioning on a call. They potentially could for performing an unsafe procedure, like cardioverting someone when it's not indicated and potentially contraindicated...

I highly doubt you'd get into trouble for not continuing to the bottom of your narrow complex tachycardia protocol with this patient. It's a volume problem, not a cardiogenic one. Treatments focusing on cardiac etiology of the tachycardia are not going to do her any good and potentially could harm her.

My protocol says I have to is not a good answer. I'm not advocating to violate your protocols at all. All I'm trying to say is they give you permission to treat up to that's level, below it is acceptable. Patients don't fit in pretty little cookbooks.

 

[Melclin]

But she fell....FULL SPINAL!

Not to divert the conversation but on the topic of O2 (RE someone saying something about it being unnecessary or bad), I don't think its unreasonable to shotgun some O2 while you're sorting this chickadee out.

I'm not saying it will do any good, that it should stay on for the entire transport, nor am I saying that it absolutely should have been done. I do however think, in the first few minutes when you know little more than hypotension, tachycardia and (now I'm making things up) they look big sick and are maybe pre-arrest, its not unreasonable to apply a reasonably high concentration O2 while the rest of the picture comes to light, you have a reliable SpO2 and the rest of your work is done.

I think we here at EMT life get a little obsessed with bemoaning the whole "15lpm for everyone" BS. There isn't a lot of definitive evidence either way on this issue as far as I'm aware, and recommendations still suggest the use of high concentration O2 initially in critical illness until things calm down enough to titrate to a gas or SpO2 of choice. Now you could argue about whether or not this is "critical illness" and it probably isn't, but I still reckon there are worse things that could happen to this chick than 8 mins of O2.

As always, happy to be proven wrong.

 

[Hunter]

But she fell....FULL SPINAL!

Not to divert the conversation but on the topic of O2 (RE someone saying something about it being unnecessary or bad), I don't think its unreasonable to shotgun some O2 while you're sorting this chickadee out.

I'm not saying it will do any good, that it should stay on for the entire transport, nor am I saying that it absolutely should have been done. I do however think, in the first few minutes when you know little more than hypotension, tachycardia and (now I'm making things up) they look big sick and are maybe pre-arrest, its not unreasonable to apply a reasonably high concentration O2 while the rest of the picture comes to light, you have a reliable SpO2 and the rest of your work is done.

I think we here at EMT life get a little obsessed with bemoaning the whole "15lpm for everyone" BS. There isn't a lot of definitive evidence either way on this issue as far as I'm aware, and recommendations still suggest the use of high concentration O2 initially in critical illness until things calm down enough to titrate to a gas or SpO2 of choice. Now you could argue about whether or not this is "critical illness" and it probably isn't, but I still reckon there are worse things that could happen to this chick than 8 mins of O2.

As always, happy to be proven wrong.

Actually we had a meeting with our new medical director that just took over about a month ago about this recently, he showed up pictures of coronary arteries of an otherwise healthy person on room air and on high concentrations of O2. The people with O2 had much more limited blood flow to the heart, it was actually scary what the difference was. The people with high flow O2 looked like they had a partial occlusion of the vessels. Also instructed us to not place patients on O2 unless they have a SaO2 of 90% or less, and that our target should be 94%.

 

[alabamatriathlete]

Guys - lets not over-think this. Fluid challenge for BP and HR (obviously heading towards a state of shock), following getting a bit more Hx from her (which yall did, finding out pt had not eaten and drank in well over the normal time period most of us humans who like to live do in) - found out she is malnourished, dehydrated, etc. Bingo :excl:

Questions I would want to ask, like some of yall have before: how long has this weakness been going on for, why haven't you been eating or drinking, other than weakness - what else is going on (i.e. other symptoms), find out about her home life (God knows - maybe abuse or neglect is the cause, not that anything is leading me to it, but part of Hx so whatever), etc.

How about a BGL? Diabetic maybe? Guessing that is way low too since no food or water. Obviously 12-lead will probably show small or no T's because she has been having odd BM so electrolytes are low - again, find out what is going on with that (color, normal, watery, for how long, past med/surg Hx).

As for the debate on SVT, A-fib/flutter, PSVT, borderline tach/SVT - start simple. If she's A/Ox3, vagal (although I'd be caution bc she has already shown she has limited control over BM), meds, cardio. Sure the S/S look like you might want to shock the chick, but like Hunter said (and a lot of yall) - more of a simple fluid/malnutrition/dehydration problem.

Possibly more underlying causes, but start simple and work advance.

My .2 cents